Article Figures & Data
Figures
- Fig 1.
FVH can be seen in acute stroke. A, In this case, blooming artifacts are seen in the right MCA M2 segment on gradient-echo imaging from an acute occlusive thrombus. B and C, FVH is noted proximal (B) and distal (C) to the arterial occlusion, which was confirmed on angiography.
- Fig 2.
FVH is often transient and is a marker of collateral flow. A, In case 1 (top row), preangiogram FLAIR image demonstrates FVH in the left temporal lobe. B, The angiogram obtained soon after demonstrates MCA occlusion and very good leptomeningeal collateral flow. The MR image obtained at 24 hours after presentation (C) demonstrates absence of FVH, the presence of T2 signal-intensity abnormality in the basal ganglia and subcortical white matter consistent with acute infarction, and a normal flow-related enhancement in the left MCA on a concurrent MR angiogram (D). The absence of FVH on follow-up imaging is consistent with restoration of normal flow. In case 2 (bottom row), preangiogram FLAIR image (E) demonstrates FVH in the left temporal lobe, and an angiogram (F) obtained soon after shows MCA occlusion and very good collateral flow. G, MR image obtained the day after demonstrates continued presence of FVH and T2 signal-intensity abnormality in the basal ganglia, consistent with acute infarction. There is reduced flow-related enhancement in the left MCA territory on a concurrent MR angiogram (D), indicating continued abnormal arterial flow.
Tables
Summary of studies describing FLAIR vascular hyperintensities
Author (Publication Year) Population Studied No. Age Range/Mean (yr) Criteria for FVH Diagnosis Study Conclusions Cosnard et al (1999)3 Acute cerebral ischemia imaged <6 hours from symptom onset 53 26–90/69 High signal from vessels on FLAIR sequences Comparison of 3D-TOF MRA and FLAIR images for stroke diagnosis FVH corresponded to MRA evidence of stenosis/occlusion; FVH correlated to the territory of brain infarction on follow-up imaging in 85% of cases Kamran et al (2000)4 Retrospective blinded analysis of 304 MRIs of patients admitted for acute MCA stroke 30 52–81 Tubular hyperintense signal relative to gray matter on FLAIR Determined the clinical correlates of FVH FVH observed in 10% of cases; FVH associated with MCA occlusion or severe stenosis; Angiographic studies correlated FVH with slow flow in leptomeningeal collaterals; NIHSS scores higher in patients demonstrating greater burden of FVH in MCA territory Maeda et al (2001)5 Review of patients imaged within 6 hours of stroke-symptom onset 11 63–88/74 Arterial hyperintensity on FLAIR images Comparison of FVH with DWI for diagnosis of acute stroke FVH present in 8 of 11 patient MRIs; FVH can precede DWI abnormalities and may provide a clue to early detection of impending infarction Toyoda et al (2001)6 Imaging within 6 hours of onset of acute cerebral ischemia caused by intracranial arterial occlusion 60 27–93/70.3 HVS Described FVH, MRA, flow voids on T2, and DWI findings in select group FVH present in 98%; FVH seen in areas outside increased DWI signal; Final infarct volume intermediate to DWI signal area and FVH area Iancu-Gontard et al (2003)8 Cases with multiple intracerebral arterial stenoses imaged nonacutely with FLAIR and control group 19 vs 19 Study group (22–67/43), control group (42.2) HVS on FLAIR = focal or tubular hyperintensities in the subarachnoid space (within dark CSF signal) Determined whether HVS is more common in patients with known intracerebral arterial stenosis High inter-reader concordance in identifying FVH; FVH seen in 68% of cases and 5% of controls; Concordance of territorial distribution of stenoses on FVH highest in MCA distribution; FVH seen mostly in high-grade stenosis or occlusion Schellinger et al (2005)12 Review of 127 patients who received rtPA within 3 hours of stroke onset 56 63–89/76 HVS Comparison of HMCAS, GRE-BA, and FVH for diagnosis of stroke and predicting response to rtPA FVH associated with vessel occlusion but has little prognostic value; FVH more sensitive than HMCAS and GRE-BA in diagnosis if large-vessel occlusion (66% vs 40% vs 34%); HVS represents slow flow whereas the other 2 signs represent the thrombus; FVH not an independent predictor of intracranial hemorrhage, recanalization, and clinical outcome, including response to rtPA Sanossian et al (2009)9 Acute cerebral ischemia imaged within 6 hours of angiography 74 43–83/63 Focal, tubular, or serpentine hyperintensity relative to gray matter in the subarachnoid space or extending into the parenchyma Description of the correlates of FVH on concurrent angiography FVH was present in 53/74 (72%) of all acute strokes with subsequent angiography; FVH was seen in areas of blood flow proximal and distal to stenosis or occlusion; FVH distal to high-grade arterial occlusion is associated with a high-grade leptomeningeal collateral blood flow Lee et al. (2009)10 Consecutive patients with MCA territory infarct imaged prior to treatment with rtPA 52 54–84/69 Linear- or serpentine-appearing hyperintensity on FLAIR imaging, corresponding to a typical arterial course in the hemisphere of arterial occlusion Study of the hemodynamic correlates of FVH FVH observed distal to arterial occlusion in 73% and proximal to 77% of patients; FVH due to collateral flow beyond the site of occlusion; FVH associated with smaller ischemic lesion volumes, as well as lower initial NIHSS scores; The presence of distal FVH before rtPA is associated with large diffusion-perfusion mismatch; FVH not an independent predictor of 5-day NIHSS
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